New Patient Forms

For your convenience we have provided the New Patient paperwork which is needed for your appointment with Matt Smith Physical Therapy. Please download the forms, fill them out and bring them with you to your consultation appointment.

Note: You will need Adobe Reader to view and print these forms. You can download it for free from Adobe.

• Patient Information (.pdf 50K)
• Informacion Del Paciente (.pdf 50K)
• Patient Medical History (.pdf 25K)
• Patient Pain Assessment (.pdf 79K)
• Financial Responsibility (.pdf 28K)
• Supplies Beneficiary Agreement (.pdf 37K)
• Medicare Beneficiary Agreement (.pdf 28K)
• Health Information Release Form (.pdf 31K)
• HIPPA Privacy Policy (.pdf 2M)
• Privacy Practice Acknowledgement - signature page only (.pdf 37K)